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Improved Outcomes with Percutaneous Image-Guided Lumbar Synovial Cyst Treatment: Novel Approaches and Techniques 2012

Interventional Spine

Leena, Tekchandani, MD
Orlando, Ortiz, MD, MBA, FACR, Non ASSR Member

Paper/Mentor

Purpose

To show improved outcomes following lumbar synovial cyst rupture in previously symptomatic patients using aggressive tandem and/or coaxial percutaneous image guided techniques.

Methods & Materials

13 consecutive patients underwent CT guided percutaneous treatment for their symptomatic lumbar synovial cysts. All patients presented with unilateral lower extremity radiculopathy with or without lower back pain. These patients chose to undergo attempted percutaneous management of their symptomatic lumbar synovial cysts. All procedures were performed under strict aseptic technique using intravenous anesthesia and CT fluoroscopic guidance. A facet arthrogram was attempted using a low osmolar nonionic contrast agent in all patients. Cyst rupture, using a tandem and/or coaxial technique, was performed in all patients using an 18 ga guide needle and a 22 ga insert needle. In those instances where the facet arthrogram demonstrated the presence of a communicating cyst, the tandem approach consisted of simultaneous cyst opacification via repeat arthrography and cyst puncture, attempted aspiration, and rupture with a second needle (18 and or 22 ga). Isolated, non-communicating, cysts were accessed via an interlaminar or transforaminal approach using coaxial technique with an 18 ga spinal (guide) needle and a 22 ga (insert) Chiba needle. Following attempted cyst aspiration, cyst rupture is performed using a 1 to 3 mL mixture of methylprednisolone (2 mL, 80 mg) and bupivacaine (3 mL, 0.5%). All patients have been followed for a minimum of 3 weeks after their procedure.

Results

Ten patients were male and 3 were female, with an average age of 65.0 years. All patients presented with severe (9-10/10) unilateral lower extremity radiculopathy, with or without low back pain. These patients had their cysts accessed either through the facet joint (indirect) or through an interlaminar or transforaminal approach (direct). The cysts did not communicate with the parent facet joint in 4 patients. 5 patients underwent coaxial technique cyst rupture and 8 patients underwent tandem technique cyst rupture. Cyst aspiration was successfully performed in 3 patients, yielding straw-colored, viscous fluid. Cyst rupture was documented in all cases by the eradication of the cyst as seen with post-procedure imaging and the presence of small amounts of contrast agent within the epidural space. The mean surveillance period in these patients was 38.08 months, with a range of 95 months and a median of 22 months. Three patients were re-treated for recurrent, though smaller, cysts, which occurred within 3 months of initial treatment. These patients have not had a recurrence at a minimum of 1 year follow-up. Also, to date, none of the remaining patients have had a recurrence. No treatment related complications were observed.

Conclusion

Aggressive tandem and/or coaxial percutaneous image guided techniques for rupture and treatment of lumbar synovial cysts reduces recurrence rates and therefore helps avoid more invasive, open surgical procedures in this group of patients.

References/Financial Disclosures

Epstein NE, Lumbar Synovial Cysts A Review of Diagnosis, Surgical Management, and Outcome Assessment. J Spinal Disord Tech 2004;4:321-325 Martha JF, Swaim B, Wang DA, Kim DH, Hill J, Bode R, Schwartz CE, Outcome of Percutaneous Rupture of Lumbar Synovial Cysts: a Case Series of 101 Patients. The Spine Journal 2009;9:899-904 Gupta A, Lutz GE, Synovial Cysts: to Fuse or Not to Fuse? The Spine Journal 2010;10:817-819 Bydon A, Xu R, Parker SL, McGirt MJ, Bydon M, Gokaslan ZL, Witham TF, Recurrent Back and Leg Pain and Cyst Reformation After Surgical Resection of Spinal Synovial Cysts: Systematic Review of Reported Postoperative Outcomes. The Spine Journal 2010;10:820-826 No financial disclosures.

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